Cook Children’s of Fort Worth is confident that its new children’s hospital in Prosper will be welcomed, even if the area north of Dallas becomes saturated with new pediatric facilities.

“We don’t believe employers or insurance companies would ever object to competition in the marketplace,” a Cook official wrote in an email last week.

That Texas value is often reflected in the state’s light approach to regulation. Texas does not require a “certificate of need” to build a hospital, for example, choosing to let the market sort things out.

But all health care competition is not equal, not in a region with high medical costs and large swaths of the population living without health insurance.

Children’s hospitals are a much different proposition, but his broader point applies: Building new facilities doesn’t necessarily mean a better deal for consumers, because somebody has to pay for the upgrade.

Two other children’s hospitals — Texas Scottish Rite Hospital for Children and Children’s Medical Center Plano — are not far away. With the latest expansions, there would be four major pediatric facilities within an 8-mile radius of Frisco city hall.

For context, the entire Dallas-Fort Worth metro region had just four children’s hospitals for years.

Children’s hospitals account for a relatively small share of total health spending, but the buildup in Prosper reflects the latest salvo in a health care arms race. Billions have been spent on new medical facilities in North Texas, including several recent additions in the Plano-Frisco area.

The Dallas region already has some of the highest prices in health care and also ranks high for usage. In 2016, overall prices in D-FW were 16% higher than the national median, according to an index compiled by the Health Care Cost Institute in Washington. That puts D-FW at No. 17 among 112 metros.

In usage, D-FW ranked sixth, with patients using 26% more overall services than the national median, according to the index.

Several factors contribute to the high costs and usage here. Economists often cite rising consolidation of hospital systems and physician practices, because doing so gives them negotiating leverage with insurers.

Texas also has higher rates of obesity and childhood poverty, and lower rates of physical activity, according to a national ranking by the United Health Foundation. Texas also ranks 38th in public health funding and even lower on adolescent immunizations.

Of course, no state has a higher share of residents without health insurance, which exacerbates the divide between the haves and have-nots.

The areas around Prosper and Frisco are growing fast, attracting scores of new families, homes and employers. But health companies also have another reason to expand there: Fewer residents go without health insurance.

"

In Prosper, the share of adults ages 19 to 64 without coverage was 6.7% in 2017. For Frisco, it was 8.7%.

In Dallas and Fort Worth, the uninsured rate for adults was nearly 33% and 26%, respectively. Likewise, in Cleburne and Waxahachie the uninsured rate was several times as high as in Prosper and Frisco.

“Where are the new children’s hospitals on the southern side of the metroplex?” said Travis Singleton, senior vice president of marketing for Merritt Hawkins, a top physician recruiting firm.

The divides are greatest in rural Texas, where some families must drive hours to find a modern children’s hospital. For those communities, the biggest challenge is attracting enough doctors, Singleton said.

Many counties have severe doctor shortages, especially in mental health and other specialties. Hospital companies don’t necessarily expand where the need is greatest, he said; they expand where there’s a strong-enough economic engine to support such enterprises.

Often, those are wealthy areas in the largest urban centers, which can be great for some — and not so great for others.

Dallas ranks among the best for short waiting times to see a doctor. The average wait across five specialties was 15 days, according to a 2017 survey by Merritt Hawkins. Odessa’s waiting time was almost twice as long, and Boston ranked lowest with 52 days of waiting.

Those standings were reversed on another metric: share of doctors accepting Medicaid patients.

In Boston, 85% of doctors accept Medicaid compared with 17% in Dallas. Unlike most states, Texas has not expanded Medicaid as part of the Affordable Care Act, and this plays out in predictable fashion.

“Patients in D-FW are really fortunate to live here — if they have insurance,” Singleton said. “But if they don’t have insurance, it’s one of the worst places to be.”